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Questions and Answers
What is a characteristic feature of primary or spontaneous bacterial peritonitis?
What is a characteristic feature of primary or spontaneous bacterial peritonitis?
Which scenario is most likely associated with secondary peritonitis?
Which scenario is most likely associated with secondary peritonitis?
Which symptom is not typically associated with peritonitis?
Which symptom is not typically associated with peritonitis?
What factor contributes to peritoneal dialysis-associated peritonitis?
What factor contributes to peritoneal dialysis-associated peritonitis?
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A 32-year-old female presents with right iliac fossa tenderness and guarding. The ultrasound reveals acute appendicitis. How would you classify the peritonitis?
A 32-year-old female presents with right iliac fossa tenderness and guarding. The ultrasound reveals acute appendicitis. How would you classify the peritonitis?
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Which laboratory test is essential to rule out pancreatitis in the diagnosis of peritonitis?
Which laboratory test is essential to rule out pancreatitis in the diagnosis of peritonitis?
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What type of imaging study is most likely to identify free fluid in a patient suspected of peritonitis without the use of contrast?
What type of imaging study is most likely to identify free fluid in a patient suspected of peritonitis without the use of contrast?
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In cases of secondary peritonitis, what type of specimen is typically required for microbiological investigation?
In cases of secondary peritonitis, what type of specimen is typically required for microbiological investigation?
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What is a key characteristic of Rigler's sign seen on imaging studies for diagnosed peritonitis?
What is a key characteristic of Rigler's sign seen on imaging studies for diagnosed peritonitis?
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Which laboratory finding would indicate an elevated response to infection in a patient with suspected peritonitis?
Which laboratory finding would indicate an elevated response to infection in a patient with suspected peritonitis?
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Which type of peritoneum is attached to the abdominal wall?
Which type of peritoneum is attached to the abdominal wall?
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What is a potential cause of generalised peritonitis as opposed to localised peritonitis?
What is a potential cause of generalised peritonitis as opposed to localised peritonitis?
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Which of the following organs is classified as retroperitoneal?
Which of the following organs is classified as retroperitoneal?
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What type of fluid is secreted by the mesothelium in the peritoneal cavity?
What type of fluid is secreted by the mesothelium in the peritoneal cavity?
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Which of the following represents a characteristic feature of bacterial peritonitis?
Which of the following represents a characteristic feature of bacterial peritonitis?
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Which of the following is a primary aspect of managing bacterial peritonitis?
Which of the following is a primary aspect of managing bacterial peritonitis?
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What is the primary aim of the peritoneal lining?
What is the primary aim of the peritoneal lining?
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Which of the following is NOT a classification of bacterial peritonitis?
Which of the following is NOT a classification of bacterial peritonitis?
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What is the primary aim of empiric treatment in the context of peritonitis?
What is the primary aim of empiric treatment in the context of peritonitis?
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Why is it essential to send a specimen of peritoneal fluid to microbiology?
Why is it essential to send a specimen of peritoneal fluid to microbiology?
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What is a significant complication of bacterial peritonitis?
What is a significant complication of bacterial peritonitis?
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Which condition is less likely to be caused by polymicrobial infections?
Which condition is less likely to be caused by polymicrobial infections?
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What procedure may be required if a PD catheter is infected?
What procedure may be required if a PD catheter is infected?
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In the management of secondary peritonitis, what is an important step after source control?
In the management of secondary peritonitis, what is an important step after source control?
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Which microorganism is indicated as having a resistance rate of approximately 50% with co-amoxiclav?
Which microorganism is indicated as having a resistance rate of approximately 50% with co-amoxiclav?
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For management of SBP (Spontaneous Bacterial Peritonitis), which treatment route is typically used?
For management of SBP (Spontaneous Bacterial Peritonitis), which treatment route is typically used?
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What is the most likely diagnosis for a 65-year-old female with ascites, confusion, fever, and generalized abdominal tenderness?
What is the most likely diagnosis for a 65-year-old female with ascites, confusion, fever, and generalized abdominal tenderness?
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Which organism is most commonly associated with secondary peritonitis following a perforated diverticulum?
Which organism is most commonly associated with secondary peritonitis following a perforated diverticulum?
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What is the primary goal in managing peritonitis?
What is the primary goal in managing peritonitis?
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Which factor is most important for differentiating between primary and secondary peritonitis?
Which factor is most important for differentiating between primary and secondary peritonitis?
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What type of antibiotics should be included for treating secondary peritonitis?
What type of antibiotics should be included for treating secondary peritonitis?
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What is the diagnostic process for establishing peritonitis?
What is the diagnostic process for establishing peritonitis?
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What characteristic of peritoneal fluid is significant for diagnosing the type of peritonitis?
What characteristic of peritoneal fluid is significant for diagnosing the type of peritonitis?
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What is a major complication of untreated peritonitis?
What is a major complication of untreated peritonitis?
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Study Notes
Anatomy of the Abdomen
- The peritoneum is a serous membrane lining the abdominal cavity and covering abdominal viscera.
- It is divided into parietal peritoneum (attached to abdominal wall), visceral peritoneum (wrapped around organs), and peritoneal cavity (potential space between parietal and visceral peritoneum).
- The peritoneal cavity contains a small amount of sterile lubricating fluid secreted by mesothelium.
- Organs may be intraperitoneal or retroperitoneal.
- Intraperitoneal organs are enveloped by visceral peritoneum, covering the organ both anteriorly and posteriorly.
- Retroperitoneal organs are only covered in parietal peritoneum, covering their anterior surface.
Peritonitis
- Peritonitis is localised or generalised inflammation of the peritoneum leading to an exudate which rapidly becomes purulent.
- It arises from contamination of the peritoneal cavity, which is normally sterile.
- Contamination may be caused by microorganisms (bacteria, fungi), irritating chemicals (bile, urine, gastric content, blood), or both.
Peritonitis Classification
- Peritonitis can be classified into three main categories:
- Primary/Spontaneous Bacterial Peritonitis (SBP)
- Secondary Peritonitis
- Peritoneal Dialysis-Associated Peritonitis (PD-Peritonitis)
Primary/Spontaneous Bacterial Peritonitis (SBP)
- SBP has no obvious source.
- It may be seen in patients with pre-existing ascites, such as those with chronic liver disease.
- SBP does not involve disruption of the abdominal wall and intra-abdominal organs.
- There is no macroscopic defect in the gastrointestinal tract.
Secondary Peritonitis
- Secondary peritonitis arises from intra-abdominal lesions/spillage.
- It may be caused by perforation of an organ, tumour, penetrating injury to the abdominal wall, acute pancreatitis, or post-procedure (e.g., anastomotic leak following bowel resection, iatrogenic perforation following colonoscopy).
Peritoneal Dialysis (PD)-Associated Peritonitis
- PD-associated peritonitis occurs when bacteria enter the normally sterile peritoneum through the PD (Tenckhoff) catheter.
- Common entry points include "touch-contamination" or exit-site infection.
- Less commonly, PD-peritonitis may be caused by an intra-abdominal source.
Peritonitis: Clinical Features
- The clinical presentation of peritonitis is referred to as "peritonism."
- Symptoms include abdominal pain, feeling bloated, and general unwellness.
- Patients may also experience nausea, vomiting, and anorexia.
- Abdominal pain may radiate to the shoulders or back and worsen with movement.
- Fever is also a common symptom.
- Peritonitis can be localised or generalised.
Peritonitis: Diagnosis
- Diagnosis of peritonitis involves a combination of clinical signs and symptoms, laboratory tests, microbiological investigations, and radiological imaging.
-
Laboratory Tests:
- Routine bloods (FBC, renal profile, liver function tests, coagulation profile, CRP)
- Amylase (to rule out pancreatitis)
- Lactate
- Blood for group and save/crossmatch (in case of surgery and/or blood transfusion)
- Venous/arterial blood gas if shock/ischaemia
- Procalcitonin (PCT) if pancreatitis
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Microbiological Investigations:
- Blood cultures
- Urine MC&S
- Peritoneal fluid specimen:
- Intra-operative specimen of pus or fluid (secondary peritonitis) for Gram Stain and culture.
- Ascitic tap (primary peritonitis/SBP) for cell count, Gram Stain, and culture.
- Peritoneal dialysis (PD) fluid for cell count, Gram Stain, and culture.
-
Radiology:
- Abdominal X-ray (erect): May miss small amounts of free air.
- CT abdomen & pelvis: Radiation and contrast are required.
- Ultrasound scan: No contrast is used. It identifies free fluid and can be performed at the bedside.
Peritonitis: Management
-
Empiric Antimicrobial Coverage: Aim to cover likely microorganisms based on the clinical scenario.
- For peritonitis, cover bowel/enteric microorganisms: Gram negatives and anaerobes.
-
Source Control: Remove the source of contamination and repair any anatomical or functional defect.
- Drainage of abscess (may be done in operating theatre, or under image-guidance in interventional radiology department).
- Appendicectomy, bowel resection, repair of perforation.
- Laparotomy: If laparotomy being performed, peritonitis may be evident as purulent or faecal material in the peritoneal cavity. This needs washout or "lavage." A fluid/faecal material specimen should be sent to Microbiology for culture and susceptibility testing.
Complications of Bacterial Peritonitis
- Bloodstream infection (BSI)
- Sepsis/septic shock
- Localised abscess/collection
- Adhesions: Fibrous scar tissue as a result of peritoneal inflammation, potentially causing abnormal attachments between visceral peritoneum of adjacent organs, or between visceral and parietal peritoneum. Adhesions may cause pain, volvulus, and intestinal obstruction.
Choice of Empiric Antimicrobial Therapy
- Primary peritonitis (SBP): IV route.
- PD peritonitis: May be treated via intraperitoneal (IP) route - PD catheter allows direct administration into the peritoneal cavity.
- Secondary peritonitis: Usually polymicrobial, so empiric therapy needs to cover both Gram negative bacteria and anaerobes.
Rationalizing Antimicrobial Therapy
- Once microbiology results become available, target/rationalize antimicrobial therapy.
- Resistant microorganisms: Escalate therapy.
- Susceptible microorganisms: De-escalate therapy.
Peritoneal Dialysis (PD) Catheter Management
- PD catheter may need removal or exchange depending on the severity of the infection.
Additional Considerations
- Always send a specimen of peritoneal fluid to microbiology to identify the causative organism(s) and determine their susceptibility to antimicrobials.
- The choice of empiric antimicrobial therapy should be based on the likely microorganisms involved.
- Source control is essential for successful treatment of peritonitis.
- Complications of bacterial peritonitis can be serious and require prompt medical attention.
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Description
Explore the anatomy of the abdomen, focusing on the peritoneum, its divisions, and related structures. Additionally, understand the implications of peritonitis, its causes, and effects on the peritoneal cavity. This quiz evaluates your knowledge of these critical abdominal concepts.
